Healthcare Provider Details

I. General information

NPI: 1033109848
Provider Name (Legal Business Name): DOUGLAS EDWARD MAZZUCA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 N BROADWAY
PENNSVILLE NJ
08070-1754
US

IV. Provider business mailing address

48 N BROADWAY
PENNSVILLE NJ
08070-1754
US

V. Phone/Fax

Practice location:
  • Phone: 856-678-4800
  • Fax: 856-678-3630
Mailing address:
  • Phone: 856-678-4800
  • Fax: 856-678-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MB04899600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: